IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MURSHIDABAD AT BERHAMPORE.

             CASE No.  CC/36/2017.

 Date of Filing:                    Date of Admission:                Date of Disposal:

     21.03.17                                      13.04.17                                20.11.19

Complainant: Gargi Roy

W/O- Suman Roy, 17/31, A.C. Road,

PO- Khagra, Berhampore,

 Pin- 742103

-Vs-

Opposite Party: 1. Manager, Punjab National Bank,

Berhampore Branch

180, Netaji Road,

Komal Gandhar Apartment, PO- Khagra,

PS- Berhampore, Pin- 742103

   2.Branch Manager,

The Oriental Insurance Co. Ltd.

B.C.A. Building, Court Compound,

PO & PS- Burdwan

 Pin- 713101

                             3.Branch Manager,

                           The Medi Assist India TPA Pvt. Ltd.

PREMEIER COURT,

4th Floor, 4, Chandni Chowk Street,

 Kolkata- 700072

Agent/Advocate for the Complainant                        : Sri. Arghya Roy.

Agent/Advocate for the Opposite Party No.1 : Sri. Nilabja Datta.

Agent/Advocate for the Opposite Party No.2 : Sri. Siddhartha Sankar Dhar.

Agent/Advocate for the Opposite Party No.3 : None.

                       Present:   Sri Asish  Kumar Senapati………………….......President.                              

                                          Smt. Aloka Bandyopadhyay……………………..Member.

                                        FINAL ORDER

Asish Kumar Senapati, Presiding Member.

One Gargi Roy (here in after referred to as the Complainant) filed the case against the  Manager, Punjab National Bank, Berhampore Branch & Another (here in after referred to as the OPs) praying for compensation alleging deficiency in service.

The sum and substance of the complaint case is as follows:-

            The Complainant is a mediclaim policy holder under the OP No.2, Oriental Insurance Co. Ltd. vide Oriental Royal Mediclaim Policy No. 313102/48/2016/2979 and policy period was from 25.01.16 to 24.01.17. The policy was covered for the Complainant, her husband, Suman Roy and her dependent Child Soumojyoti Roy. On 05.08.16, the husband of the Complainant, Suman Roy became ill at about 1.05 P.M. and he admitted at Divine Nursing Home Pvt. Ltd. till 08.08.16 and paid Rs.24,231/- for treatment of her husband and she also spent Rs.5,630/- after post hospitalization and paid Rs.591/- for pharmacy bill. The Complainant intimated the matter of treatment to the OP No.3 on 06.08.16 vide intimation No. 40375484. On receiving claim form from the OP No.3 through E-mail, the Complainant submitted the claim to the OP No.3 on 06.09.16 and the OP No.3 received the claim form by putting its official seal and signature. As the Complainant did not get any amount, she issued a letter dated 16.01.17 requesting the OP No.2 to pay the claimed amount but of no result.

            Hence, the Complainant prayed for a direction upon the OPs to pay Rs.29,861/- for medical expenses for treatment of her husband and to pay Rs.10,000/- for mental pain and agony.

            The OP No.1, Punjab National Bank contested the case by filing written version on 14.07.17 contending that the Complainant has a   mediclaim policy for the period from 25.01.16 to 24.01.17 vide policy No. 313102/48/2016/2979. The OP No.1 has no deficiency in service and the dispute is between the Complainant and the OP No.2 and 3. The OP No.1 prays for dismissal of the complaint against the OP No. 1.

            The OP No.2, Oriental Insurance Co. Ltd. contested the case by filing written version on 31.07.18. It is the specific case of the OP No.2 that the petitioner is covered by a mediclaim policy being No. 313102/48/2016/2969 valid from 25.01.16 to 24.01.17. The OP after receiving the relevant documents from the petitioner, sent the same to Medi Assist Insurance Co. TPA Pvt. Ltd. for scrutiny. From the documents and discharge certificate issued by Divine Nursing Home Pvt. Ltd., it is found that the husband of the Complainant was admitted in Divine Nursing Home Pvt. Ltd. on 05.08.16 with a complaint of left side Hemorrhagic Pleural Effusion. In the Nursing Home routine investigation and medical treatment was done and hospitalization was particularly for diagnostic and evaluation purpose which can be carried out as outpatient. Moreover, there was no active line of treatment during hospitalization period. The condition of patient does not require hospitalization. As the claim falls under policy exclusion clause 4.10, so the claim is not admissible. There is no deficiency in service on the part of the OP No.2 and the complaint is liable to be rejected.

            The OP No.3 did not contested the case in spite of service of notice.

            On the basis of the above version the following points are framed for proper adjudication of the case :

Points for consideration

1. Isthe Complainant a consumer under the provision of the CP Act, 1986?

2. Has this Forum jurisdiction to entertain the complaint?

3. Have the OPs any deficiency in service, as alleged?

4. Is the Complainant entitled to get any relief, as prayed for?

Point no.1

The Ld. Advocate for the Complainant submits that she is a consumer as she hired services of the OPs for consideration.

On going through the complaint, written version and other materials on record and on a careful consideration over the submission of both sides, we find that the Complainant is a consumer in terms of section 2 (I )(d) (ii) of the C.P.Act, 1986 as she hired services of the OPs for consideration.

Point No.2

                    The Ld. Advocate for the Complainant submits that the cause of action arose within the territorial jurisdiction of this Forum and the claimed amount is also within pecuniary limit of the District Forum.

On a careful consideration over the materials on record, we find that the cause of action arose within the territorial jurisdiction of this Forum and this Forum has pecuniary jurisdiction to entertain the complaint.

Point Nos.3&4

            The Ld. Advocate for the Complainant submits that the Complainant is a policy holder of PNB Oriental Royal Mediclaim Policy and her husband Suman Roy  who was covered under the policy was admitted in Divine Nursing Home on 05.08.16 as per advice of Dr. Sujit Kr. Saha. He argues that Sumar Roy was under treatment of Dr. Sujit Kr. Saha sinch 01.08.16 and he referred the patient to Divine Nursing Home for admission as the patient suffered from chest pain and other complications. He draws our attention to the xerox copies of prescription issued by Dr. Sujit Kr. Saha. It is contended that the Divine Nursing Home discharged the patient on 08.08.16. It is argued that the Complainant paid Rs.23,640/- to Divine Nursing Home Pvt. Ltd. on 08.08.16 against receipt No. MR16019589 and she also paid Rs.591/- to Divine Nursing Home for medicine on 08.08.16. It is contended that the Complainant is entitled to get Rs.24,231/- from the OP No.2 and 3. He also submits that the Complainant is entitled to get compensation of Rs.10,000/- for mental pain and agony.

            He argues that the Op No.2 has deficiency in service as it has not settled the claim for a long period.

            The Ld. Advocate for the OP No.1 submits that there is no consumer dispute between the Complainant and the OP No.1 and the Op no.1 is an unnecessary party. He prays for dismissal of the complaint against the OP No.1

            In reply, the Ld. Advocate for the OP No.2 submits that the Complainant is a mediclaim policy holder but the claim of the Complainant is not tenable. He submits that the hospitalization of Suman Roy at Divine Nursing Home Pvt. Ltd. was not for his active treatment but it was for diagnostic and evaluation purpose which can be carried out as outpatient procedure. He draws out attention to the policy exclusion clause 4.10 “expenses incurred at hospital or Nursing Home primarily for evaluation/diagnostic purpose which is not valid by active treatment in the element during the hospitalized period.’’ He argues that the Complainant is not entitled to get the claim from OP No.2.

            It is urged that the OP No.2 has no deficiency in service.

            The Ld. Advocate for the Complainant argues that Suman Roy got admitted in Divine Nursing Home as per instruction of Dr. Sujit Kr. Saha vide his prescription dated 04.08.16 as he suffered from chest pain and other complications. It is urged that Suman Roy was an indoor patient from 05.08.16 to 08.08.16 and his treatment was conservative as per discharge certificate issued by Divine Nursing Home dated 08.08.16. It is urged that the treatment of the patient, namely, Suman Roy at Divine Nursing Home Pvt. Ltd. cannot be said that it is not followed by any active treatment of the ailment of Suman Roy at Divine Nursing Home. He prays for a direction upon the OP No. 2 to make payment of the cost of treatment incurred by the Complainant and compensation of Rs.10,000/- against the OP No.2.

            Perused the written version, evidence, written argument and documents filed by both sides. Admittedly, the Complainant is a mediclaim policy holder of PNB Oriental Royal Mediclaim Policy being No. 313102/48/2016/2969 valid from 25.01.16 to 24.01.17. Admittedly, the policy was covered for treatment of the husband of the Complainant, namely, Suman Roy and he was treated as indoor patient at Divine Nursing Home Pvt. Ltd. from 05.08.16 to 08.08.16. We find that Dr. Sujit Kr. Saha advised Suman Roy for admission at Divine Nursing Home as the patient suffered from chest pain and other complications. The Divine Nursing Home Pvt. Ltd. diagnosed the patient’s left side Hemorrhagic Pleural Effusion and his treatment was conservative and discharged the patient with advice to review after 5 days with consultant. The OP No.2 argues that conservative treatment is not an active treatment and so the complainant cannot claim the expenses of treatment of Suman Roy as the treatment of Suman Roy is only for evaluation and diagnostic purpose as per clause 4.10 of Happy Family Floater Policy,2015.

            On a careful consideration over the materials on record, we find that Suman Roy got admitted at Divine Nursing Home as per advice of Dr. Sujit Kr. Saha dated 04.08.16. It is not that Suman Roy got himself admitted at his own will for investigation or other purposes as Dr. Sujit Kr. Saha advised the patient for his admission at a Nursing Home and the patient was admitted on 05.08.16 and discharged on 08.08.16 with certain advice, we cannot say that the treatment of Suman Roy was not active treatment and his treatment could be done as outpatient. Moreover, the OP No.2 has not even repudiated the claim of the Complainant in spite of lapse of a considerable period from the date of receiving the claim.

            In our considered opinion, the Complainant is entitled to get Rs.24,231/- (which was spent for treatment of Suman Roy at Divine Nursing Home) from the OP No.2. We also think that the OP No.2 has deficiency in service for not settling the claim of the Complainant within a considerable period.

            We think that the Complainant is entitled to get compensation of Rs.2,000/-from the OP No.2 for deficiency in service and mental pain and agony.

            We also find that the Complainant is not entitled to get any relief against the OP Nos.1 and 3 as there is no consumer dispute between the Complainant and OP Nos.1 and 3.

Reasons for delay

The Case was filed on 21.03.17 and admitted on 13.04.17 . This Forum tried its level best to dispose of the case as expeditiously as possible in terms of the provision under section 13(3A) of the CP Act,1986. Delay in disposal of the case has also been explained in the day to day orders.

Fees paid are correct.

In the result, the complaint case succeeds. Hence, it is

                          ORDERED

that the Consumer Complaint Case No. CC/36/2017 be and the same is hereby allowed on contest against the OP No. 2 without cost  and dismissed on contest  against the OP No1 without cost and . dismissed against the OP No.3 exparte without cost. 

The OP No. 2 is directed to pay Rs. 24,231/- to the Complainant by 60 (sixty days) from the date of this order.

The OP No. 2 is further directed to pay compensation of Rs.2,000/- to the Complainant by 60 (sixty days) from the date of this order for deficiency in service and mental pain and agony.

          Let plain copy of this order  be supplied free of cost, to each of the parties / Ld. Advocate/Agent on record, by hand  /by post under proper acknowledgment  as per rules, for information and necessary action.

The Final Order will also be available in the following Website:

    confonet.nic.in

Dictated & corrected by me.

          President

  Member                                                                                  President.